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Biomedical subjects

P D Kiernan

Publications and source records attributed to P D Kiernan.

At least 19 recordsLinked to original sources
PubMed2006

Thoracic esophageal perforation: one surgeon's experience.

Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. In the following retrospective analysis, we have examined all cases of thoracic esophageal perforations diagnosed, consulted, and/or treated by one author (PDK) at the Inova Fairfax Hospital from June 1, 1988 through March 17, 2005. These cases consisted of 48 patients (34 male) with a mean age of 59.4 years (range, 20-92). Among 25 patients with early diagnosis (< or = 24 h), hospital survival was 92%, increasing to 96% when early diagnosis was combined with surgical treatment. Among the 23 patients with late diagnosis (> 24 h), hospital survival was 82.6%, increasing to 92.3% when treated with surgery. We recommend aggressive, definitive surgery for thoracic esophageal perforations, regardless of time of diagnosis. In the absence of phlegmon or implacable obstruction, primary repair offers excellent results with the shortest length of stay. Resection and reconstruction are the best choices in circumstances where significant phlegmon or distal obstruction render primary repair hazardous or inapplicable. Diversion, preferably with proximal and distal esophageal exclusion, may be necessary for patients too ill to undergo more formidable surgery. Conservative, medical therapy may be appropriate in patients with 'microperforations' with no continuing leak. Finally, comfort measures alone may be appropriate where circumstances merit no effort at resuscitation.

Adult↗
PubMed1998

Managing the patient with perforated intrathoracic esophagus.

The thoracic perioperative specialty team members at Inova Fairfax Hospital, Falls Church, Va, designed guidelines to improve the management of patients with esophageal perforations. They performed a retrospective analysis of 41 patients who were diagnosed with thoracic esophageal perforations from Sept 1, 1979, through Sept 1, 1996. The review affirmed their philosophy of aggressive, surgical intervention for perforations, particularly for patients diagnosed early (i.e., within 24 hours). The process of examining and communicating the results among OR nurses, anesthesia care providers, and surgeons resulted in the increased efficiency and appropriateness with which patients were incorporated into the hospital's surgical and medical treatment groups.

Adult↗
PubMed1998

Descending cervical mediastinitis.

Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA-Fairfax-Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.

Abscess↗
PubMed1997

Urokinase thrombolysis as initial therapy for acute and non-acute ischemic extremities.

Limb ischemia, both acute and chronic, presents a risk to life and limb with mortality rates from 3% to 37% and amputation rates of the same range. Our experience with urokinase thrombolysis as the initial therapy for acute and non-acute ischemic extremities over 57 consecutive cases of native arterial occlusion by either thrombus or embolus has resulted in no mortality and only 3.5% requiring amputation (2 of 57). In 74% of cases initial thrombolytic therapy was followed by either balloon angioplasty (35 patients) or surgery (7 patients) to relieve the underlying cause of obstruction (i.e., stenosis, occlusion or aneurysm). Thrombolysis alone was sufficient and effective treatment in the remaining 26% (15 patients).

Adult↗
PubMed1996

Bilateral lung volume reduction surgery.

A new surgical approach, bilateral lung volume reduction surgery (LVRS), offers hope for select patients with chronic pulmonary emphysema (CPE). Bilateral LVRS procedures involve excision of emphysematous alveoli, which results in a 20% to 30% reduction in the volume of each lung. The goal of LVRS is to improve the respiratory mechanics of patients with CPE by reexpanding functional lung tissue compressed by overdistended emphysematous alveoli, restoring diaphragmatic mobility, and improving the bellows function of the chest wall structures. Patients undergoing bilateral LVRS procedures experience relief from chronic dyspnea and may note improved pulmonary functions and better quality of life.

Humans↗
PubMed1994

Stage II and III-A non-small cell cancer of the lung: results of surgical resection at Fairfax Hospital.

Carcinoma of the lung is the single leading cause of death in patients with cancer and is responsible for over a quarter of all such deaths. Encouraging survival rates have been demonstrated following surgical resection of local (Stage I) disease. This paper details the results achieved with surgical resection of 100 patients with more advanced local--regional non-small cell carcinoma of the lung (Stages II and III-A). Operative (30-day) mortalities were 2.4% for Stage II patients and 8.5% for Stage III-A patients. Respective, 5-year Kaplan-Meier survival estimates were 41% (+/- 10%) and 36% (+/- 7%) and included all deaths, cancer-related as well as unrelated. When patients were stratified by stage, neither gender, age, cell type, tumor size, nor extent of resection proved statistically significant relative to long-term survival. However, Stage III-A patients, classified T-3 with contiguous tumor involvement of mediastinum, suffered a higher operative mortality and a significantly lower probability of long-term survival (p = 0.04). Finally, the results and appropriateness of prospective, clinical trials utilizing adjuvant therapies in Stage II and III-A patients and neo-adjuvant therapies in Stage III-A patients are discussed.

Adenocarcinoma↗
PubMed1993

Aneurysm of an aberrant right subclavian artery: case report and review of the literature.

In this article, we describe a case of a surgically treated aneurysm of an aberrant right subclavian artery. The historical literature to date is summarized, as are the key concepts relative to the anatomy, embryology, diagnosis, and treatment of this uncommonly occurring entity. Although the topic might be expected to be of concern to only a few specialists, all physicians should be aware that a patient with an enlarging aneurysm of an aberrant subclavian artery may experience dyspnea, dysphagia, or sudden collapse from rupture as the initial manifestations. An asymptomatic patient may have a mediastinal mass detected by roentgenography. The diagnosis may be confirmed with computed tomography or magnetic resonance imaging. As with most aneurysms, surgical treatment is recommended, and the benefit-to-risk analysis depends on individual case factors.

Aneurysm↗
PubMed1993

Stage I non-small cell cancer of the lung results of surgical resection at Fairfax Hospital.

Between January 1, 1981 and December 31, 1989, 2003 patients were evaluated at Fairfax Hospital with a diagnosis of carcinoma of the lung. Of these, 214 with Stage I non-small cell carcinoma underwent surgical resection. Operative (30-day) mortality was 1.4%. Overall 5-year survival was 59%, inclusive of all deaths, cancer-related as well as unrelated. Noting stage was constant, when patients were analyzed by gender, age, cell type, tumor status and extent of resection, only age proved statistically significant relative to long-term survival. However, even patients 70 and older averaged a nearly 50% 5-year survival. Moreover, if deaths are related to cancer only, 5-year survival rates should be significantly increased over the rates when quoted to all causes of death.

Adenocarcinoma↗
PubMed1993

Resection for esophageal carcinoma at a Virginia hospital 1981-1989.

Between January 1, 1981 and December 31, 1989, 222 patients with carcinoma of the esophagus were seen at Fairfax Hospital. Fifty-eight (26.1%) underwent esophagogastrectomy. Operative (30-day) mortality was 8.6%. Follow-up was 98.3% complete. Of hospital survivors, 38 (76%) were resected for potential cure versus 12 (24%) for palliation. Consistent with the experience of others, a minority of patients (26%) presented with early (Stage I & II) disease; forty patients (69%) were noted to be Stage III or IV at time of resection and three patients (5%) were stage indeterminant. The five year Kaplan-Meier product limit survival estimate for Stage II patients was 52%, versus 22% for stage III, and 0% for Stage IV.

Adenocarcinoma↗
PubMed1992

Thoracic esophageal perforations at a Virginia hospital 1979-1990.

A study was made of all patients who underwent management for distal esophageal perforation at the Fairfax Hospital from September 1979 to September 1990. The study group consisted of 13 patients. Nine were male, four female. Mean age was 60.8 yrs, ranging from 36 to 83 yrs. In the group of nine patients diagnosed early (less than 24 hrs), hospital mortality was 22.2% versus 75% in the group of four diagnosed late (greater than 24 hrs). Of the six patients treated conservatively, either medically or surgically, only one survived, but all seven patients diagnosed early and aggressively operated upon survived. Thus the authors agree with others in espousing aggressive, definitive surgery for patients diagnosed early.

Adult↗
PubMed1984

Hemodynamic response to positive end-expiratory pressure following right atrium-pulmonary artery bypass (Fontan procedure).

Thirteen patients were studied in the early postoperative period to determine the hemodynamic response to increasing levels of positive end-expiratory pressure (PEEP) following right atrium-pulmonary artery bypass (Fontan procedure). Hemodynamic data and arterial oxygen and carbon dioxide tensions were measured without PEEP and with PEEP = 3, 6, 9, and 12 cm H2O. Cardiac index decreased progressively with increasing levels of PEEP compared to PEEP = 0 (cardiac index = 2.7 +/- 1.2 L/min/m2), and the decrease was significant at PEEP = 9 (cardiac index = 2.2 +/- 0.8 L/min/m2, p less than 0.05) and 12 cm H2O (cardiac index = 2.0 +/- 0.7 L/min/m2, p less than 0.05). Both arterial oxygen tension and pulmonary vascular resistance index increased significantly at all levels of PEEP studied compared to PEEP = 0. Significant positive trends were demonstrated for arterial oxygen tension and pulmonary vascular resistance index and a significant negative trend was shown for cardiac index with increasing PEEP. Heart rate, right atrial pressure, left atrial pressure, mean arterial blood pressure, and arterial carbon dioxide tension did not change significantly nor consistently with increasing PEEP. From these data it appears that PEEP is an effective means of raising arterial oxygen tension after right atrium-pulmonary artery bypass. A progressive fall in cardiac index occurs with increasing PEEP, and the fall becomes significant at PEEP greater than 6 cm H2O. The fall in cardiac index appears to be mediated by a significant rise in pulmonary vascular resistance index.

Adolescent↗
PubMed1982

The hemodynamic response to dopamine and nitroprusside following right atrium-pulmonary artery bypass (Fontan procedure).

Cardiac output is critically dependent upon pulmonary vascular resistance after right atrium-pulmonary artery bypass (Fontan procedure), since there is no pulmonary ventricle in the circulation. Inotropic agents, including dopamine, may increase pulmonary vascular resistance and, therefore, might have an adverse effect on cardiac output. The present study determined the hemodynamic responses to dopamine and nitroprusside of 9 patients following right atrium-pulmonary artery bypass. Particular attention was given to effects on cardiac output (CI), pulmonary vascular resistance, and right atrial pressure (RAP). Baseline hemodynamic data were measured without drugs, with dopamine at 7.5 micrograms/kg/min, with sodium nitroprusside up to 5.0 micrograms/kg/min, and with a combination of dopamine, 7.5 micrograms/kg/min, and sodium nitroprusside, 1.0 micrograms/kg/min. Right and left atrial pressures (LAP), mean arterial blood pressure (BP), heart rate (HR), and CI were measured. Stroke volume index and pulmonary arteriolar resistance index were calculated. The increase in CI from baseline (1.98 +/- 0.86 liters per minute) was significant for infusions of dopamine (2.75 +/- 1.05, p less than 0.001), sodium nitroprusside (2.57 +/- 0.78, p less than 0.001), and both drugs (2.74 +/- 0.84, p less than 0.001). The increased CI was achieved primarily by a significant increase in HR with dopamine and by an increase in stroke volume index with sodium nitroprusside. With a similar increment in CI, the RAP was significantly decreased from baseline (21 +/- 4 torr) with sodium nitroprusside (15 +/- 3, p less than 0.001) but was unchanged with dopamine. Pulmonary arteriolar resistance index decreased significantly from baseline (375 +/- 230 dynes sec cm-5/m2) with sodium nitroprusside (169 +/- 132, p less than 0.001), and, interestingly, with dopamine as well (273 +/- 165, p less than 0.05). Both dopamine and sodium nitroprusside in these dosages have favorable effects on CI and pulmonary arteriolar resistance index in patients after right atrium-pulmonary artery bypass. Whenever feasible, sodium nitroprusside is preferred for increasing CI after such a bypass procedure, since lower RAP decreases the severity of fluid retention, ascites, and chest tube drainage.

Adolescent↗
PubMed1981

Patient acceptance of mastectomy for cancer.

Of 300 women who had mastectomy for breast carcinoma, 278 (93 percent) responded to a questionnaire about how well they accepted loss of a breast. Of those responding, 73 percent stated that they had no appreciable adverse reaction to the extent of the operation. Twenty patients (7 percent) cited major work, social or sexual problems resulting from mastectomy. Among the 20, sexual problems--cited by 85 percent--predominated. Four (1 percent) of the 278 patients expressed major dissatisfaction with the cosmetic result of an external prosthesis. Two of these patients and four others had surgical reconstruction of the breast, which was satisfactory in five.

Breast↗
PubMed1980

Annular pancreas: May Clinic experience from 1957 to 1976 with review of the literature.

From a review of 266 cases reported in the literature and data on 15 other patients operated on a the Mayo Clinic for symptomatic, annular pancreas, the following three conclusions can be made. First, annular pancreas is an uncommon congenital anomaly, often not becoming symptomatic until late life. Second, complicating congenital and acquired disorders must be recognized it patients are to be properly prepared for surgery. Sometimes associated problems may be recognized, whereas the annular pancreas may be overlooked. The change of this happening is decreased by methodical inspection of the entire abdomen, especially all segments of the duodenum, because annuli can occur in any segment and can be partially or completely circumferential. Third, while there is no single operative procedure of choice, published experience militates against any direct attack on the offending annulus.

Adolescent↗
PubMed1980

Occult papillary carcinoma of the thyroid.

Retrospective review was undertaken of 137 patients with occult papillary carcinoma of the thyroid (lesions less than or equal to 1.5 cm in diameter) who were operated on at the Mayo Clinic, Rochester, Minn, between 1926 and 1955. Mean follow-up period was 25.3 years. Operations were conservative. No patient underwent bilateral total lobectomy. For 55 patients with lymph node involvement, lymphadenectomy generally involved selective node excision or modified neck dissection. Subsequent surgery was required in 12 patients; modified radical neck dissection was necessary in only four. No operative deaths occurred. Long-term follow-up showed that all patients were alive and without disease or were dead without proof of thyroid-related disease. Thus, occult papillary thyroid carcinoma with or without nodal metastasis is a nonlethal and curable disease when treated by conservative surgical means. Radical surgical or medical extirpation of all thyroid tissue is unnecessary in the treatment of this disease.

Adolescent↗
PubMed1980

The surgical management of bleeding stress ulcers.

The series included 52 patients with acute bleeding stress ulcers of the stomach and duodenum seen at the Mayo Clinic during a 25-year period. All patients underwent operation for control of massive bleeding that was unresponsive to intensive medical therapy. All ulcers were superficial and occurred during clinically stressful circumstances. No patient had a history or findings suggestive of pre-existing peptic ulcer disease or imbibation of ulcerogenic substances. Overall operative mortality was 54%, and this rate seemed to be related to multiple factors acting together; patients with multiple predisposing stress factors and those requiring large transfusion volumes (greater than 17 total units) were at greatest risk of death. Fifty-two patients underwent 60 operative procedures for control of hemorrhage. Of the 60 procedures, 23 (38%) failed to prevent rebleeding. Of the 28 patients who died, six (21%) died of hemorrhage and five (18%) died of hemorrhage as one of many contributing factors. Of eight different procedures performed, near-total to total gastrectomy was the single procedure that was most effective in controlling hemorrhage. The authors support the selection of rapid intervention and generous extirpative surgery once intensive medical measures fail to control hemorrhage.

Adolescent↗
PubMed1980

Aortic graft-enteric fistula.

Fifteen years' experience with 20 patients undergoing 24 operations for intestinal bleeding from aortic graft-enteric fistula at the Mayo Clinic has been reviewed. A review of the English language literature permits analysis of an additional 127 patients who underwent surgical intervention for this condition. Associated operative mortality in our experience and in that of others has been high--55% and 46%, respectively. Long-term survival in both groups remains low--approximately 15%. Consideration has therefore been given to aspects of prophylaxis, diagnosis, and intervention which may minimize future morbidity and mortality.

Aged↗